Application of multiple intraoperative monitoring techniques in microsurgery for anterior communicating aneurysms

Objective To evaluate the efficacy of combined multiple intraoperative monitoring techniques including transcranial Doppler (TCD), indocyanine green angiography (ICGA) and neuroelectrophysiological monitoring consisting of somatosensory evoked potential (SEP) and motor evoked potential (MEP) in the surgical management of anterior communicating aneurysm. Methods Clinical data were analyzed for the 23 patients who underwent microsurgery for anterior communicating aneurysms with assistance of combined multiple intraoperative monitoring techniques. Twenty⁃three patients [12 males, 11 females; mean age 52 (range 44-63 years)] underwent aneurysm clipping via modified pterional approach. Total vein anaesthesia was used for all patients. Propofol, fentanyl and scoline were administrated before intubation. Remifentanil and propofol were used throughout the procedure. Internal carotid artery and A1 segment of anterior cerebral artery were exposed successively. The parent artery, perforating artery and aneurysm were carefully recognized after the A1 segment was temporarily occluded. The temporary clip was removed after the aneurysm being clipped. Neuroelectrophysiological monitoring, ICGA and TCD were applied for intraoperative monitoring. Results All of the 23 aneurysms were successfully clipped. MEP changes were seen in 6 patients during the temporary occlusion of A1 segment, which directed neurosurgeon to pause for its recovery. TCD and ICGA detected A2 segment or anterior communicating artery stenosis in 2 patients and residual aneurysm in 1 patient during clipping procedure, which directed neurosurgeons to readjust aneurysmal clips. Postoperative transient hemiparalysis were observed in 1 patient with modified Rankin Scale level 1 at discharge. No hemorrhagic or ischemic events were observed in other 22 patients with modified Rankin Scale level 0 at discharge. Conclusion Combined multiple intraoperative monitoring techniques may provide important information for the tolerance of A1 segment temporary occlusion, residual aneurysms and ischemic events in the parent or perforating arteries in microsurgery of anterior communicating aneurysms. DOI：10.3969/j.issn.1672⁃6731.2012.01.004